Basic Information
| Provider Information | |||||||||
| NPI: | 1114369089 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MADDEN | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | INGERSON | ||||||||
| OtherFirstName: | KATIE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 95 E CHAUTAUQUA ST | ||||||||
| Address2: | |||||||||
| City: | MAYVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147571017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7167537107 | ||||||||
| FaxNumber: | 7167535367 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 PRATHER AVE | ||||||||
| Address2: | SUITE 100, 200, & 400 | ||||||||
| City: | JAMESTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147016820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163380022 | ||||||||
| FaxNumber: | 7163381567 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2013 | ||||||||
| LastUpdateDate: | 10/13/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 016751 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.